Jim Thorpe. The World's Smartest Man?

I never understood the argument that athletes get paid too much. A kid grows up, shows up at practice, usually for multiple sports in the rain and snow and heat. Sweats, works, develops skills. And then at the end of 15-20 years or so of hard work it pays off with a 10,000 to one shot and a pro contract. I always imagine the people who complain the most are people who’ve never worked really hard for anything in their life.

"I worked really hard. I just chose to develop my brain,” they would counter. But they'd be comparatively lazy. They only developed their brain. Athletes develop their brains too, but the development is done through structured and dedicated bodily movement. It is a different part of the brain, but it is still the cortex. It's still neurons and synapses blending and communicating. It's still neuroplasticity.

Research into stroke recovery has revealed a simple truth: If someone was an athlete, at any point in their life (not necessarily right before their stroke), they have a better chance of a more full recovery. Why might former athletes do better? Is it because the movement portion of the brain, the part that is typically injured after stroke, is bigger in athletes? Or is it because athletes are used to training insanely hard for results?

I asked this of a neurologist and neurosurgeon, Prithika Chariwhen when we met at a shared talk in Munich 3 years ago. Her answer was simple (considering she was a brain surgeon); “Probably both."

Stroke survivors need to be athletes. By extension stroke survivors also need to be dancers and yogis and musicians. Work as hard as athletes.

And for all those nincompoops who think using your motor cortex is just plain dumb, click on this.

The Forgotten Leg

Constraint induced therapy (CIT) and modified constraint induced therapy (mCIT). We know them and we love them. These recovery options are richly researched and intuitive. I mean really, how much thought does it take? "If I tie up my 'good’ arm, and work really hard with my 'bad' arm and hand it will move better.” Duh, hello.

The concept of CIT has been extrapolated to everything. For instance there is CIAT (constraint induced aphasia therapy). CIAT is based on the same old idea: If the stroke survivor forces themselves to talk a lot, talking gets better. In many ways a constraint induced therapy is the trunk from which all the theoretical branches spring. And that trunk is as solid as it can be. "Practice makes perfect.” “We are what we repeatedly do.” “Use it or lose it.” Cliché, cliché, cliché but true, true, true.

All good news to be sure. But one bit of the body that has been left to drag behind: The leg. How would you do the CIT for the lower extremity (LECIT)? You could tie up your good leg, but falls, decubitus ulcers, hospitalization, throwing a clot, having another stroke, so let's say… no.

But still the idea is compelling enough for researchers and device makers across the rehabilitation spectrum to want to claim LECIT as their own. I wrote an article about the competing perspectives.

The bottom line is that to adhere to the spirit of constraint induced therapy, you have to overstress the affected leg. And this requires caution. And a therapist. And a lot of work.

Two Great Tastes

Figuring out what helps a stroke survivor recovery may involve finding that one magic bullet. But it probably won't. It will probably be a few magic bullets, a smattering of magic hand grenades and a ton of magic TNT. Enough of this explosive rhetoric!

The point is, recovery requires multiple recovery strategies. As time goes on, the combination of strategies will change.

There is a tendency among many researchers to focus on their little piece of the pie. They'll pioneer treatment "X". They'll develop treatment "X". They'll advocate "X" and they'll cling to "X" forevermore.

Our lab takes a bit of a different tact. If different things work for different survivors at different times you damn sure better have a feel for the whole ball o' wax.

Here is a recent study our team did fusing "Two great tastes that taste great together".

Bon appetit!

Another Coward With A Gun

OK. So a gunman goes into a nursing home and kills 7 nursing home patients. What a coward. "The slain patients ranged in age from 78 to 98." Whats next? "I'm going to blow away people in hospice!"

The killer was 45. He was ..."armed with a rifle, a shotgun and other weapons." I mean, if you're in that much of a rage, wouldn't you look for some sort of challenge? What could the possible motivation be?

"My knee's been acting up. I need someone slower than me!"

I've worked in nursing homes. My wife is a PT in one that looks almost exactly like the one that was attacked. This one, in NC, was focused on folks with Alzheimer's. Cowardly, weird, sad, the end.

THE HISTORY OF STROKE RECOVERY

INTRODUCTION

This is the history of stroke recovery. This is a perspective that is uniquely my own; a simplified version of a narrative built up in my head over the years. It will be in multiple parts. How many parts? Well, answering that question would involve fancy-underpancy planning, to which I have an aversion.

Histories are important because they tie people, which is what people like to think about (generally), to events. In this case “events” refers to the ambling from there to here; from not knowing what a stroke was to understanding quite a bit about not only stroke, but recovery, too. Like most of our collective story, it all starts with cavemen… I wrote an article about it. And there is a chapter in my book, about how cavemen might have handled stroke. (One editor suggested I change every “caveman” to “caveperson” which I didn’t do because really?)


PART I: 
STROKE RECOVERY, THE EARLY YEARS

Anyway…so it starts with our ancestors that lived in caves. More accurately, it wasn’t about where they lived, but how much they moved. They moved in hunter-gatherer tribes. These were small bands of individuals, begat (!) from our common Mom (or “CoMom”), Lucy. These folks walked and walked and walked, always on two legs. Two leg walking was good because allowed us to see more stuff (because we were taller), and use our hands to carry junk (because they weren’t doing anything else and we feared they’d dwindle into tiny T-Rex-style flippers with claws) and keep us cool in the Kalahari heat (because standing provides less surface area). As you can see, I’m no anthropomorficologist, but this is my story, so I’ll filter the facts the way I see fit thank you.

So we walked and roamed and found stuff and ate it. We were also really good at hunting because, although we're not the best sprinters, we were great at distances running and walking. So we would run after edible beasts at our own two-legged pace. Once we caught up to them, it was a 2 fer 1; They were too tired to run and/or fight, and they were so hot they were already half-cooked!

If an individual had a stroke, there would have been a general feeling that some sort of higher power was pissed. It was probably an omniscient female deity, because all of our deities were female back then. And no wonder. There is now a belief that our numbers shrunk to just a few thousand at one point, probably because of a severe drought. So anything that could give birth would be seen as (as Kung-Foo Panda would say) awesome and attractive. So once the ever-pregnant She-God decided you needed a smack-down, a smack-down smacked upon thee. And if She chose, she would give you a "smack upside the head", which is what cavefolk used to call a stroke. And as I mentioned in my article, there would have been a serious effort to get the stroke survivor on their feet and the “therapy” would have been focused and ferocious. And it would be directed not by a therapist, but by survival instinct. This instinct knows no rational bounds, and no stinkin’ stroke was going to stop us from surviving. The survival instinct is just not something we access much any more.

We’re now in the “fat and happy” part of evolution (anthropomorficologically speaking).

This is how I've put it earlier:

Early humans and hunter-gatherer tribes of today may have had one advantage over present-day humans: A capacity for hard work. These were rugged people who survived using extreme strength and physicality. They knew what hard physical work was and they knew no other lifestyle than that of survival.

Intensity and frequency of post-stroke rehabilitation is one of the hot topics among stroke researchers. Research has shown that patients spend as little as 13 percent of their day (8 a.m. to 5 p.m.) involved in rehabilitation efforts within the first 14 days after the stroke while spending 78 percent of their time in bed or sitting next to their bed. Might the ability of our evolutionary cousins to couple their huge capacity for physical work with the natural demands of life in a hunter-gatherer tribe have some lessons for today's stroke survivor?

Modern-day researchers believe there are lessons. This belief is reflected in so many of the newer recovery options that involve so many more hours of work. "Intensive therapy" and "over-challenge" is the way researchers put it. We’re trying to get stroke survivors, by hook or by trick, to access their inner survival instinct.

PART II: THE GREEKS ADD THEIR 2¢

And that’s the way it stood for 3 mill plus years. You’d get a stroke and you’d fight like hell to get back to where you once belonged.

Hippocrates showed up 2400 YEARS AGO and did something remarkable: he defined stroke. He wrote about stroke and aphasia and TIA’s (transient or “mini” strokes). He made up a word for it: Plesso. Which meant “Slapped upside the head by God.” 250 years later another Greek doc, Galen, said that he thought stroke was “thick and dense humors” built up in the ventricles of the brain. Which, you know, is a pretty good guess that sounds a bit like an ischemic (block) stroke. Galen was pretty interesting. He was the personal physician to Marcus Aurelius and Commodus, two of the characters in one of my fav flicks, Gladiator.

Then nada for a thousand years or so and then the Germans came up with the word “strAcian” whch loosely meant “bonked on the head with a kilo of Spätzle.” The derivative of this word is stroke. But Hippocrates’sess’s word, Plesso was the basis for the word apoplexy, which you still hear on old Andy Griffin episodes.

PART II: THE CLASS OF 1950

Working in the early 1900’s, Sir Charles Sherrington was a colossus of all things neurological. Sherrington was a Nobel winner (1932, functions of neurons). It is hard to explain how ginormous this guy was. His ideas on what drove human movement were law. One of his hypotheses was called reflexology. Reflexology basically said that all control over muscles came from the spinal cord, and was just a series of reflexes. The brain got involved, sure, but just a filter for the prime mover: reflexes.

“Sherringtonian reflexology” was adopted by many of the most influential physical therapists that ever lived. Sherrington had a great influence on PT and OT as it related to stroke. His influence was especially strong from the 1950's to the 1990's. From the '50s to the '70s was when physical and occupational therapy was just beginning to address stroke-specific therapies. The problem is they had inaccurate tests, so it was difficult to determine if what they were doing was actually working.

They had another problem, as well. Some therapists took Sherrington’s reflexology and smeared it on every aspect of stroke recovery like a kid with hot toast and runny peanut butter. For his part, Sherrington disavowed the idea that it was all about reflexes (and accepted that movement was controlled and learned in the brain) by the late '40s. Hey, he was a bright guy and a true scientist; if new evidence comes to light, you change. If you want definitive answers, look to religion.

The problem was that a few influential therapists, most forcefully Berta Bobath, never got the memo that it is in the brain, not the spinal cord, that control resides. In her book Adult Hemiplegia (1970), Bobath began writing about, teaching and generally espousing that it was all about reflexes—which come from the spinal cord. Bobath also believed the way survivors naturally move after stroke was so bad that therapists should not allow the movement to take place. The way that survivors move is called synergistic movement. It is still believed, by many therapists influenced by Bobath to be movement so evil that Bobath and her followers set about separating stroke survivors from the only movement they had! Fast forward to 2000 and the Bobath Center (sorry, Centre), the British seat of all things Bobath. They issued the following statement: “While certain activities are not encouraged in some cases, the idea of stopping a client from moving, especially if they are motivated to do so, cannot be supported on financial, moral or scientific grounds.” But it has been difficult to let go of a core concept that had been a cornerstone of the Bobath approach for decades. For example, in 2008 an article (p.133) defending the Bobath approach wrote, "Abnormal/atypical patterns of coordination need to be suppressed and unwanted movements controlled..." Under this premise, you'd need someone with you during the entire arc of recovery. Otherwise you might move wrong.

Stroke survivors need the ugly movement to get to good movement. Imagine yelling to a baby, “Look at you, you duck-footed fool! Bend your knees and stop falling!!” Imagine telling someone who is learning a language (or instrument, or anything), “Stop making mistakes!” Learning requires mistakes. Mistakes corrected are learning.

Bobath’s therapy, called neurodevelopmental technique (NDT) is still very popular, but it’s not very scientifically-based. (See Here. Here. Here. Here. And a great non-scientific discussion here). My suggestion is to avoid therapists who say I’m a “this-based therapist, or a that-based therapists.” Instead, look for therapists who say something along the lines of, “I’m an evidence-based therapist. I consider the best science and meld it with my clinical experience.”

Weirdly, a contemporary of Bobath, Signe Brunnström, who also published her best known work in 1970, was clear right out the box: Use any movement, synergistic or not. We now know we need to encourage “ugly” movement to rewire the brain neuroplastically. Not only that, but Brunnström suggested really forward thinking concepts that are accepted by stroke-recovery researchers all over the world. Among them were Brunnström’s “6 stages of recovery.” Despite the fact that Hippocrates had defined stroke 2400 years before, Brunnström was the first person to fully delineate the predictable steps towards recovery. It turns out that her stages of recovery are so accurate that they can be correlated with brain-scanning technology like MRI (see Here and here). Just like Einstein, Brunnström predicted stuff and then waited for the world to catch up. The bad news was that Bobath’s NDT was wildly more popular than Brunnström’s techniques. Why was Bobath more popular than Brunnström? It may have been a simple issue of duration of message. Brunnström was diagnosed with Alzheimers and began to live in a nursing home in 1976. Bobath died in 1991.

PART III: TAUB BUCKS THE POWERS THAT BE

Edward Taub represents the full-on separation from the “reflexes rule” argument. He showed, through animal testing that, even when you get rid of reflexes (with an operation that cuts nerves to the spinal cord) you can still learn new movement. Repetitive practice movement drives changes in the brain. Those changes lead to better movement. This ushered in constraint-induced therapy, and other ideas that were as simple as pie: repeat a movement and that movement will get better.

Just like the cavefolk did.

Well duh. And it only took us forever to figure out what we already knew.

My daughter wants to to play soccer now. The End.

Radio Interview

I did a recent radio interview with Karla Calumet, a very nice professor and radio personality from Perry, Iowa. So get some tea, sit back, and...

ADDENDUM: 2.11.14: THIS RECORDING IS NO LONGER AVAILABLE-FOR SOME REASON :<

Stroke Struck. Rock Roll.

"I know a rock star. His name is Dave Grohl. He was the drummer in the band Nirvana and now heads the Foo Fighters.

I haven't talked to him since a thrilling evening in Atlanta backstage at a Nirvana concert in 1994. But I know how he got to be an amazing drummer. And it wasn't easy. First, let me tell you why his story has everything to do with (stroke recovery)."

I wrote this article last year. It's really about the power of very intense bursts of repetitive practice on learning (or relearning) movement.


Play me until you get blisters

I'm a drummer as well. Drumming is interesting because it hits (heh heh) on so many leading-edge topics in stroke recovery. One is cognitive. It turns out that there is a company that uses keeping a beat to drive better cognitive recovery. Drumming is also inherently bilateral (left, right); and bilateral training is a hot stroke-recovery idea. It may even help with the only long word I remember from school, dysdiadokinesia, an inability to do alternating (bilateral) movements after brain injury. Why did I remember it? Dude. I'm a drummer. And this brings up the next point: use what you love to drive recovery. The more intensely you love doing something the less it becomes therapy and the more it is just plain fun. Whats the old saying, "If you love your work, its not work."

I'm jus' sayin'

Folks involved in rehabilitation research (like me!) have a lot to answer for. I read studies all the time. It’s almost impossible to figure out what the actual intervention (treatment) is. It's usually deep in the article as a couple of short sentences that tells you sort of what happened. If you read two or three articles about the same intervention you can piece them together, and get a feel for how to do the intervention. I work for a major university. I have access to all the articles I want. Even articles that are not on line because they are too old I have access to.

How is the typical therapist supposed to find the articles and have the time to sort the whole article out? I have no idea. And it sucks because it has consequences on the treatment of stroke survivors. I think that there should be a law that says that if you are doing any sort of research on human participants (subjects) that there should be a one-page explanation, in clear, simple and plain language that everyone can understand, what the intervention was, and what its clinical application is.




This photo is my son Jesse’s reaction when I told him about how researchers are trying to hoard all the thinkology.

Little = Lots

I love this study. It was a small study that our lab did. Basically we used the NeuroMove and got people to move their wrists and fingers, just a little. The point is, if you can find the X factor that allows for just a little active (under your control) finger and wrist extension, then you can use other options to take you further. But the trick is getting the first few degrees of movement. And we did it. The end.

The body after stroke. Working in mysterious ways.

Stroke is weird; unlike most neurological diseases, stroke is nonprogressive... A stroke survivor doesn't get more brain damage as time goes on. Unlike multiple sclerosis, Parkinson's, Lou Gehrig's disease, etc. stroke and other forms of brain injury do not get worse over time.

And through the process of neuroplastically rewiring the brain recovery happens. So there is an argument that can be made that says people can actually get "better" after stroke. This is going to sound twisted but... the stroke tells you what needs to be worked on. In other words, the very deficits that stroke presents are the exact things that need to be worked on to recover from stroke. It's hard to do, but stroke survivors should embrace those deficits as acceptable challenges.

There are other “deficits” after stroke that may also have a sort of internal logic. (Note: Deficits related to stroke--and other primary diseases are called sequelae).

Can sense be made of all the sequelae we fight so hard to get rid of after stroke? Is there a reason for them?

• Movement close to the body (proximal, i.e. the hip and the shoulder) returns before movement that is far away from the body (distal, i.e. hand and foot). Why might this be? It may be because you can't do anything with the distal unless you can get the distal where it needs to be by using the proximal.

• Spasticity is a reality for many stroke survivors. Spasticity may be considered internal protection mechanism, generated by muscles, to protect muscles.

• Stroke survivors with one sided weakness can rarely move one joint without moving a whole bunch of other joints. This is called synergistic movement. In the hand and arm there are two such movements: the flexor synergy, which looks very much like a hand to mouth. There is also an extensor synergy. This movement looks very much like picking something up. If there are any movements that you don't want to lose they are feeding movements. These synergies look very much like feeding movements.

• Heminopsia (a one sided visual deficit -- difficulty seeing towards the affected side) and unilateral neglect (ignoring the affected side) may provide a lack of focus on what does not work and focusing on what does work.

How stroke survivors can be so wrong it hurts them.

“A pessimist is one who makes difficulties of his opportunities and an optimist is one who makes opportunities of his difficulties.”

~Harry Truman

In my job I do a lot of outcome measures (tests) of stroke survivors . I test the movement of arms and I test legs and I test spasticity and I test reflexes and on and on. I almost always end up having the same conversation with stroke survivors.

• Survivor: “I can’t move my arm. It’s paralyzed" While they this they usually bring their arm across the chest.
• Me: “You’re moving it right now” 
• Survivor: “I guess, but its useless”
• Me: "Can you move your hand?" “NO, not at all." (I ask these questions to get a ballpark of where they are in their recovery. These are just preliminary questions before I launch into the full battery of tests--which can take hours.)

And on the conversation goes...

• Me: I’ve learned not to trust stroke survivors on the "Can you move your hand" one.
• Stroke survivor: "Even Dr. – (A prominent local doctor) said I can’t move my hand! "
• Me: "What do doctors know?" (I JOKE.) I take their hand and open it. They usually have some spasticity but I'm usually able to open it pretty fully.
• Me: Squeeze my hand.

Their fingers came into a fist.

I’ll tell you why they think they have no movement; therapists and doctors tell stroke survivors they no FUNCTIONAL movement. Unfortunately what they hear is that they have no movement that would do any good, so they didn’t bother using the movement they have.

This leads to further loss of cortical (brain) representation of the muscles involved. Active movement is lost and, probably, passively will eventually be lost. On the other hand, if therapists had left stroke survivor with the following, they would have been a lot better off:

“You have great movement. You are lucky because many survivors are flaccid. They are so weak that the muscles that hold the shoulder in place can’t even do that... so they have a permanently dislocated shoulder. So you are in good shape—something is going on and when something is going on you can build on that. But from here on out, you have a responsibility to the bad-side arm, hand and leg. If you are willing to work very hard you can get more movement out of the arm and leg. The more you use whatever movement you have, the more movement you will gain. You’ll gain muscle. You’ll force more of your brain to control that side and you will get more movement. This will require a lot of work including many repetitions on 'the edge of your ability'--where movement is the hardest. But you will make gains."

So you can continue to believe that you can’t do anything with the arm and this will happen: The amount of brain dedicated to that arm will be lost. The muscle thickness in that arm will be lost. The muscle strength will be lost. The muscle length and the PROM will be lost. Eventually the limb will be turned into an “appendix limb” with no use other than aesthetics. “I might as well cut off this arm. It just gets in the way.” 

Or you can believe that your arm will get better and you’ll work with it. If you do this, the following will happen: The amount of brain dedicated to that arm will increase. Spasticity will decline. The muscle thickness in that arm will increase. The muscle strength will increase. The muscle length and the passive movement will increase. It will probably never get as good as it once was, but it will, to some degree, recover.

Splain' the Brain: 4 Brain Books That Rawk.

I've read a ton on the brain. I read articles and blogs and books. Some of what I've read are downright unreadable; either poorly written or so detailed, science-y and specific that there were no real practical applications. And that's what I'm looking for: practical applications. I either want the book to be a tool I can use to help stroke survivors, or a tool I can use for myself.

Hey, my brain can use some work as well...

There are four books I've read recently and while all of them have we redeeming qualities, I like some more than others.

The first book of my list is Jeffrey Schwartz's book
"The Mind and the Brain: Neuroplasticity and the Power of Mental Force".

The whole book is really good, but the part on stroke recovery is brilliant. This book provides the historical back story for stroke recovery. Every stroke survivor and clinician working with stroke survivors, should read these chapters. It makes you feel in your bones what recovery is made of.



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The second book I like is called Synaptic Self: How Our Brains Become Who We Are, by Joseph E. LeDoux. This book is a relatively easy read and helps one understand the importance-- not of neurons (nerve cells)-- but of the connections between neurons (synapses). It's a hopeful book because these connections have a vast potential for growth. Generally speaking the number of neurons will not grow, but the connections between neurons can. Developing new connections is the essence of stroke recovery, and learning. Brilliant.



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The third book that's interesting is The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science, by Norman Doidge. It's a fine book, but I find much of the historical perspective of stroke recovery the same as Jeffrey Schwartz's book, which was written three or four years earlier.


__________________________



The book I'm reading right now is called The Body Has a Mind of Its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better by Sandra Blakeslee and Matthew Blakeslee. The jury is still out on this one. It has some interesting tidbits scattered throughout. Not much of it is specifically related to stroke recovery, but it does have interesting comments about mirror therapy and mental imagery in stroke recovery.

I'm a big fan of mirror therapy as a potential aid. There is a whole chapter on it in my book. In terms of mental practice or imagery, our lab has done ( and continues to do) many studies in this area. If you're interested in our work on mental practice as related to stroke recovery, here is an example.

Young Stroke Survivors: Unique Ambitions Drive recovery.

Young stroke survivors are interesting to those of us in stroke-specific rehabilitation research because there is so much raw material and raw potential. Many younger stroke survivors have the effects of the stroke as the only problem they have. They are often not on meds, they have tons of energy, and they are not willing to give up the balance of their life.

Here is the gist:

Stroke in adulthood: A normal architecture, altered. Imagine building a new house. You build a good foundation, a solid frame, a strong roof, etc. You put in the plumbing, electrical, and walls. Your new house is done. Then one day you have an accident! You back your car into the corner of the house. That part of the house needs to be fixed. The foundation is still there, the solid frame still exist in most of the house, the roof is still good; plumbing, wiring, everything is still good. You only need to fix that one room.

•    A stroke in adulthood affects a normally developed brain. The size and location of the stroke determines what skills are lost.

•    Stroke in childhood: An altered architecture. Now imagine you neighbor builds a house, but he’s not a very good builder. The foundation is uneven and the frame is crooked. Everything that is built around the foundation and frame is affected by the poor basic architecture of the building. To “fix” the house would require starting from scratch.

•    A stroke in childhood affects how the brain develops. The brain in childhood is a blank slate. Neurons (nerve cells in the brain) haven’t “decided what they want to be when they grow up,” and whatever is imprinted on that blank slate affects the way the brain develops. Children have an immense amount of brain plasticity available to them. After stroke, children often do amazing things, given the amount of brain injury they have. There are classic examples of children who have a complete hemisphere (half of their brain) destroyed by stroke. In an adult, such a stroke would institutionalize the person for the rest of his or her life, but some children survive and thrive with half a brain. They are able to learn to read, write, have a sense of humor, be productive, and enjoy life. So it is unfair to describe the brain after a childhood stroke as having “poor architecture.” In fact, it could be considered “excellent architecture” given the amount of brain damage they have.

The impact of stroke before the brain is fully developed is much different than the impact of stroke after the brain is fully developed. The process of recovery in the two is very different, as well. In fact, it is only in the adult brain that is truly “recovery.” In childhood stroke becomes a part of development.

A Lot To Live Up To: "The Magic Cure for Spasticity Reduction"

More than any other aspect of stroke recovery, stroke survivors and therapists ask me about spasticity. Are there effective treatments? Can spasticity be eliminated? What do I do?

There are many treatments for spasticity, but all of them are Band-Aids. That is, they don't eliminate spasticity; they mask it or temper it. Treatments range from injections that temporarily "quiet" the offending muscles (i.e. Botox, phenol blocks) to drugs that usually work systemically (which means they hit all your muscles and usually have a global sedative effect). There are surgeries that snip a nerve rootlet here or a tendon there (these are permanent and nor reversible; they eliminate spastcicty, but also eliminate the potential for the muscle ever to come back.)

There is one answer, however. It is outlined in this article I wrote recently.

Trust me, I did not make up the headline.

Bilateral Training

Assume you never had a stroke. If you are right-hand dominant and you are trying to do something equal and opposite (like drumming) your right hand will slow so the left hand can keep up.

But it works in the opposite as well...your left hand will be able to drum faster, will have better trajectory and make fewer mistakes if you do the drumming with both hands at the same time... together. The right hand essentially trains the left hand.

After a stroke the unaffected "good" arm/hand will train the "bad" arm/hand. It's called 'bilateral transfer'. This transfer of info from one limb to the other, some scientists think, happens below the brain; right through the spinal cord, as if the two limbs are communicating directly. this may be one of the (many, many) reasons the legs usually come back sooner; bilateral transfer is used constantly during the one activity the legs are most involved in...walking. Want it to sound more scientific-y? Here's my slide for it...

Dammit Jim I'm a Doctor

Four or five years ago I created a PowerPoint slide for a series of talks that my colleague and noted stroke recovery researcher Stephen J. Page do. It was sort of a joke slide; above is a copy of it. The idea was that at some point in the distant future Dr. "Bones" McCoy would have a machine that you simply point at a stroke survivors brain that makes the boo boo go bye-bye. Of course it was a joke ha ha.

A few months ago we got a transcranial magnetic stimulation (TMS) machine that has a special aiming feature on it. You play it like a video game. First MRI data is fed into the TMS machine. This allows for whoever is doing the treatment to see the person's brain as they "zap" it with electromagnetism. The treatments are being done by a couple of our lab's physical therapists. When the stroke survivors brain is "zapped" the the muscle that corresponds to that part of the brain, the part of the brain they are targeting, twitches.

The B1XGX: Stroke Eliminator. Not such a joke anymore.

The Secret to Recovery. Period.

I think I've found the answer to recovery from stroke. Honestly. Call the Nobel committee. The answer may be in the first Q&A in an article I wrote with the help of John Farrell of Saebo. And realize, you don't need any equipment to do this, Saebo or otherwise. If you have any questions, email me 'cause it gets a bit complicated. Intuitive, but complicated.

Survivor Must Haves

There are two publications, both free, that provide information that may be essential to recovery. If you are really on the ball regarding emerging recovery technologies, then these may be a bit low-level. But even if you do a good job of figuring out what's new in the stroke recovery game, these two magazines will still be helpful.

Stroke Smart and Stroke Connection. Great articles (usually of the feel-good variety), research updates (in easily read format) and advertisements. And its the ads that I read it for because some of the technologies that our lab tests, as well as others form smaller manufacturers are in these mags. Basically, SS and SC are quick and easy ways to keep on top of whats goin' down. Order them on line or call them.

Stroke Smart 800-787-6537
Stroke Connection 1-888-478-7653

Wine and Movement.

Motor. Motor. Motor. That's all you ever hear about when it comes to stroke recovery. In rehabilitation research we tend to obsess over movement. Movement quality, movement speed, and how movement effects function. Of course movement is only half the equation. The other half is the feeling of movement. Now-- I know, you're thinking, "Oooh, he's going to get all squishy with the feelings..." Nope. The feeling of a movement is an essential to learning how to move. If you cannot feel the movement, every time you do the movement, it's like the first time. Lack of feeling the eliminates an essential part of the motor learning feedback loop. I did a talk recently to therapists and between spiels a therapist came up and told me that, like me, she thought that the feeling of movement (called proprioception) could be re-taught after stroke. And she put it in a very interesting way. She said it's like learning to appreciate fine wine; at first you can't tell table wine from a 1939 Château-whatever. But over time, as your palate develops, you learn to taste subtle differences. Bottom line: proprioception can be re-taught.

Chicks dig smart...

I am currently reading the Cambridge handbook of expertise and expert performance. I do this all the time; I buy really fat books (this one has almost 900 pages) mostly to impress my wife. Then I find myself drawn into them bit by bit. It turns out that this book has quite a bit of information that relates to stroke recovery.

I do a lot of seminars talking to therapists about stroke recovery. I generally push neuroplasticity (“brain rewiring”) as the foundation for all recovery from stroke. And the easiest way to rewire the brain is to do repetition of whatever movement the stroke survivor is trying to recover. The therapists, curious lot that they are, always ask, “How many repetitions of the movement have to happen before the brain rewires?” The problem is that this question cannot be answered with a-one-number-fits-all answer. The number of repetitions needed depends on how much movement there is to begin with, how focused the stroke survivor is in the practice, how complicated the movement is, etc. etc. The very fat book I'm reading says that there is general agreement that to become an expert in anything takes 10 years. We also know that to become a very high-level athlete, musician, or acquire a skill like carpet weaving takes more than 1 million repetitions of the movement(s).

So the question I have is, when does recovery end? After 1 million repetitions? After 10 years? If either of these is in the right ballpark, another question follows, “Why are stroke survivors discharged from therapies within a year or so of their stroke?”

Yay!

Stronger After Stroke is one of the highest ranking books on stroke rehabilitation or stroke recovery. Luminaries such as Janet Carr (who I have a post about, further down) and Joel Stein, MD (a well known stroke recovery expert/physiatrist) have books out that are ranked a bit lower than Stronger. Jill Bolt-Taylor (A Stroke of Insight) is going to be on Oprah today. My book shows up on the same page as hers on web sites, so I fully expect to be able to buy a boat before the day is through.

Check out the screenshot for rankings.


And here's a photo of my new boat...


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The Splint That Bounces Back

The wrists and hands of stroke survivors are always a challenge. In human beings the powerful muscles that close the hand and bend the fingers are essential for everything from climbing to carrying to to pulling.But after stroke, just like many of the muscles on the affected side, these large wrist and finger bending muscles get spastic. And when they do they overpower the much smaller muscles that extend the wrist and fingers.

    After stroke the fingers and wrist are flexed almost all the time and these muscles shorten and the wrist and fingers become even harder to straighten.
   The way occupational therapy has traditionally dealt with this problem is to splint the wrist and fingers. Occupational therapists (OT's) use a material called thermoplastic which is shaped into what is considered a good position for the wrist and fingers.

   But there's a problem with these splints. First of all, the splint is only as good as the OT's skill. Second these are static/rigid splints; that is, if the fingers get more flexible these rigid splints don't take advantage of these gains. Conversely if range of motion is lost and the fingers get tighter the splint does not reflect that change either. This can be damaging to the tissue around the fingers and wrist as the hand is forced into a rigid splint that's too "small".

   You could hire an OT every few months to fabricate a new splint, but that gets costly. I'm actually a big fan of a product called the SaeboStretch. This split is not static. It moves as your hand moves. If you want to bend your fingers, you can. This splint is made out of material that is flexible but elastic. That is, it can be bent but it always wants to return to its original position. This provides low-load pressure into the proper position. In this way this splint takes advantage of any increased elasticity in muscles and other soft tissue. I've had experts on splinting tell me point-blank that this is the only off-the-shelf splint that they'll recommend.

You can find information on the splint here.

A Good Excuse to Watch Football

When I worked at the Kessler Institute, a big rehab hospital in New Jersey, I worked with exercise physiologist Quin Bond. He changed my perspective about stroke recovery. The way athletic trainers and exercise physiologists look at stroke recovery is different from the way therapists typically view it. Therapists generally view recovery from stroke as a finite proposition. There is a beginning and an end. Most of scientific medicine views stroke recovery the same: finite. Exercise physiologists tend to see stroke recovery is infinite. Athletic trainers, the same. If you're used to working with athletes you're used to people who see progress is infinite. Athletes are always trying to make themselves better at their sport, stronger and faster. There is no difference between athletes and stroke survivors. Stroke survivor simply lower-level athletes playing higher stakes game. There's very little that works with athletes that doesn't work with stroke survivors. Every fundamental concept in athletic training can be superimposed on stroke recovery. Again, lower-level, but the same basic concepts hold true. Training concepts that athletes use can be used to recover from stroke. Basic concepts such as multiple hours (massed) practice, weight training, cardiovascular training, pushing the limits of ability and cross training, etc. all work superimposed on stroke recovery. The bottom line is that stroke survivors should see athletes as inspirational figures.

The photo is of Steve Prefontaine who exemplified the pursuit of the infinite.

Stroke recovery: A Leap Of Faith

I wrote this article recently. I describe Stroke recovery as a leap of faith, not unlike other leaps of faith we constantly take. Here are some highlights...

• I talked to a stroke group the other day. They were about 30 strong, and they were feisty. I do talks all over the country on the state of stroke recovery research. I have spoken to audiences that have included therapists, doctors and researchers. But nothing is quite like staring down the barrel of a group of stroke survivors. They've lived through stroke and have, to whatever degree, experienced the loss of control that defines brain damage. Each person who survives stroke is dealt a unique "hand of loss" causing the dispossession of everything from language to limbs, from emotions to personal independence. Stroke survivors have literally been there and back. They can be a bit prickly when someone suggests that they need to work harder. And that's just what I was suggesting.
• Much of what I believe helps a stroke survivor recover involves a leap of faith. I believe that massed practice works. Massed practice involves literally massing hours of practice together. I believe repetitive practice works. Repetitive practice involves doing the same movement, repeatedly, until long after sanity screams to stop.
• I believe that there is no way to recover unless the stroke survivor stays aware of new developments for stroke recovery as they emerge. I think stroke survivors need to have a strong cardiovascular and muscular foundation in order to have the energy to do all the other things necessary to recover to the highest level of potential. In short, I believe that stroke recovery is best served if efforts toward recovery are treated like a full-time job

Convincing the Experts

• When I speak to therapists about this emerging research-based paradigm shift, there is some push back. Therapists give me a sideways look and let me know that I'm whistling a bit of Dixie if I think that most stroke survivors are going to be willing to carry out a complicated and labor-intensive plan.
• Stroke survivors are more blunt. "Six hours a day of practice! I have better things to do, thanks!" They also ask questions that require absolute answers. "If I do put in the time and effort, what return can I expect?" they demand. "What about the repetitive practice? How many times do I have to repeat a movement before my brain rewires enough to do the movement right?"
• I've learned to be direct when answering. I tell them, "There are no guarantees. You could work very hard and get very little return. No one knows how many repetitions are needed. Some people think the magic number is 10,000. Others think it's closer to 150,000. Some researchers suggest a million or two. But even if we knew the 'optimal' number, the fact is that the number of repetitions needed is different for every survivor because of any number of variables." Well, to stroke survivors, this is the cherry on top of a mud pie, let me tell you. But I have an ace up my sleeve—and that ace is a mirror.
• I asked the members of the group what they did before their stroke. One gent had been a lawyer. Another was a farmer. And I have just spent three years writing a book. The three of us were a collective of experts in leaps of faith.
• I suggested to them that the monumental challenge of law school followed by the bar review then the bar exam (a three-day, six-hours-per-day exam) were several leaps of faith. Betting the farm on the mysterious and unpredictable miracle of life, year-in and year-out, through flood and draught, is the farmer's perpetual leap of faith. And what of the three years spent writing a book distilling the very message I was now telling them? This may have been the ultimate folly. I am guaranteed of selling only five copies—all of them to my mom."

Falls. Only funny in the movies.

There are few luminaries in the stroke recovery game that I really respect. Few bring anything new and most just add to an expanding din of quasi-misinformation. Two that I do respect are Carr and Shepard. These two Aussie therapists are vanguards of the paradigm shift that stroke recovery theory is now in. They have a book called Stroke Rehabilitation (go figure) that has some gems in it. One of those gems is about what causes falls after stroke. I hate falls. Heck, I’ve broken bones falling. For stroke survivors, falls can be the beginning of the end. There is a statistic that has always resonated with me: If someone is 65+ and they have a fall that lands them in hospital for at least one night they have a 50% chance of dying in the next year! And up to that 70 % of patients have a fall in the six months after their stroke.

So what do Carr and Shepard say about falling? Falls very often happen in four situations:

• Starting walking

• Stopping walking

• Turning

• Uneven surfaces